Dear HM Coroner

PREVENTION OF FUTURE DEATH RESPONSE FOLLOWING THE INQUEST INTO THE DEATH OF DAVID THOMPSON

MATTERS OF CONCERN: USE AND UNDERSTANDING OF THE TERM “SUICIDAL IDEATION”

I am writing in response to the Regulation 28 report into the prevention of future deaths notice, that was issued on 10 February 2026 and sent to the Chief Constable of Devon & Cornwall Police, James Vaughan.

The Chief Constable has asked me to respond to this notice, as the matters of concern raised therein fall within my area of policing responsibility. Please therefore treat this correspondence as the Chief Constable’s formal response to the Regulation 28 Notice.

The Chief Constable and myself want to take this opportunity to express our condolences to Mr Thompson’s family and friends. We are sincerely very sorry for their loss.

Additionally, the Chief Constable and I also want to thank you for bringing the matters of concern set out in the Regulation 28 Notice to our attention. We welcome opportunities to give serious consideration to any matters of concern such as this with a view to improving the service that we provide the public, and to assist you and your coronial colleagues in your investigations.

Devon & Cornwall Constabulary acknowledges the concerns raised regarding the use and understanding of the term ‘suicidal ideation’ within operational decision- making and communications with members of the public.

As a Force, we will continue to deliver refresher training to Control Room Staff to further strengthen their understanding of suicidality, associated risks, and the dynamic and fluctuating nature of such incidents.

Assistant Chief Constable Police Headquarters, Middlemoor, Exeter, Devon, EX2 7HQ

Guidance issued in 2024 clarified that the term ‘suicidal ideation’ refers to thoughts of suicide (with reference to publications within the Lancet, and commentary provided in open-source by the Samaritans within which ‘ideation’ relates primarily to ‘thinking about suicide or could be making a plan to take their own life. This can range from a passing thought to a detailed plan’). This clarification has been further reinforced and incorporated into training and operational guidance that is being issued and delivered throughout 2026 – with specific emphasis on the wide variety of incidents and risks that the term encompasses.

Training for Control Room supervisors and staff continue as part of ongoing refresher programmes. With greater focus, these sessions explore the definitions, meanings, and associated risks linked to suicidality. Staff are reminded that language used when assessing and communicating risks must remain clear, concise, and understood within its basic meaning.

Whilst ‘suicidal ideation’ may be considered a clinical term in some contexts, the Force recognises that in emergency situations and when communicating with members of the public, it is often more appropriate to use plain language that is not prescribed or confined to a single definition. Accordingly, operational practice encourages the use of straightforward terminology such as ‘thoughts or feelings about suicide’ when discussing potential suicide risk.

Officers and staff are also reminded that suicide risk can fluctuate rapidly, particularly where factors such as intoxication, significant trigger events, or access to means change (this list is not exhaustive). The Force recognises that over-reliance on rigid definitions, structured terminology, or scripted questions, may create false reassurance and could potentially increase risks. For this reason, operational messaging within Control Room refresher training and frontline operational guides prioritises the use of clear, accessible language and encourages open questioning to fully understand the circumstances being reported and avoid ‘language-driven information loss’.

Control Room teams are therefore encouraged to use plain language and to ask broader exploratory questions, rather than relying on a single question relating specifically to ‘ideation’, when assessing risk.

Consequently, the following actions have been taken: -

1. Continued emphasis on the use of plain language throughout Control Room refresher training which will continue to be delivered throughout 2026.
2. Formal clarification within 2024 guidance that the term ‘suicidal ideation’ simply means ‘thoughts or feelings of suicide’ – this continued to be reinforced.
3. Reinforcement of the above approach to frontline officers and staff through the introduction of operational guidance (Op Guides) relating to incidents involving Article 2 risks and suicidality.

4. Recognition that ‘suicidal ideation’ is not a nationally standardised policing term; therefore, communications and training have been undertaken to ensure staff understand the broad spectrum of risk that the term may encompass.

We have also undertaken some work with other Forces and have become aware of a ‘Ovenstone criteria’ (A criteria formed in 1973 by Dr. Irene Ovenstone) Whilst predominantly an investigative method to assist in determining whether a death was likely to be suicide, it is also useful for determining suicidal risk and provides some evidence of suspected pre-suicidal criteria and we are actively exploring this use.

Devon & Cornwall Constabulary remains committed to ensuring that officers and staff are equipped with the knowledge, language, and operational guidance necessary to identify and respond appropriately to individuals presenting with suicide risk.